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11/11/2005 FRI 08: 40 FAX f�001 <br /> �jimnrn l F4ealth Department Unit EV W, rPPie i",titSanJoaquin County �t/ <br /> JQB AapREss;_. 353 /3E u . oa.� PERMIT sem: <br /> LICENSED GONTRACTORS DECLARATION (LOIS <br /> I hereby affirm that I am llrensed under the provislonS of Chapter 9 (commencing with Secbon 7000)of Division <br /> 3 of the Business and Pfofessi ns Code and my license is In full force and ffed. <br /> License it: -1.� D <br /> Exp' on oaten: h�` <br /> Date- _Contra r <br /> SlgnatuCe `FYtia7 <br /> Pstnted name.- <br /> I <br /> WORKF_r2S' COMPENSATI DECLARATION <br /> I hemby affirm under penalty of PequrY one of the following deolamtions; (CHECK ONE) <br /> I haand will maintain a certificate of consent to sett-insure for workers' compensat on,as provided for <br /> ve <br /> by Section 3700 of the Labor Code, for the perfomnauce of the work for which this permit is issued. <br /> xI have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carYier an policy num s are= <br /> Lanier: L Policy Number. <br /> I certify that lin the pertomlance of the work for which this permit is issued, I shag not employ anyperson <br /> that f I In <br /> any mannerco aLtO pecotne subjectto the Workers compensator laws of California, and agree <br /> should become subOd to the workers'compensa'on provisions d Section 3700 of the Labor Cade, I shall <br /> forthwith complYN011 those pravi�.lons. ` <br /> Date:_ <br /> Signature; <br /> Printed Name: `— r <br /> WARNING;FAILURE 1-0 SECURE WORKERS'COMPENSATION COVERAGE IF UNLAWFUL,AU SHALL SUBJECT <br /> AN EJViPLOYER TO Gk1NUNAl PENALTIi--_'o AND CIVIL FINES I1P TO ONE HUNDRED 7HOA!3AND DOLLARS <br /> ADDITION <br /> T N HE OFT OF COMPE EFLA OR N5ATION,IN7 ERE5T,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED OR N <br /> TMORIZATI FCaR 0,7 THAN'C-57 SIGNING PERMIT APPLICATION <br /> _(alflnalum ofC-57 licanyad authorized representative), <br /> F — — <br /> hereby autlwrize(print nAmo) — <br /> tb sinn thla Sem Joagnre CotlntY Wall Permit Application on my behalf. !understand 5:;-,k ar6lhorizaglnn io "lid for <br /> one(9)YPAr:aid rs limited to¢ho work plan dace®un the•izonl payr05 t81i2.appncatloN. <br /> RFfFT11Fn TTNAF NIM/ 11 A� FAAM <br />